Appeals court upholds Tennessee’s Medicaid reimbursement cap

MM Curator summary


The TN rule designed to reduce spending on inappropriate ED spending has been upheld.


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The Court of Appeals in Nashville, Tenn., ruled that TennCare, the state’s Medicaid program, did not violate a state law when it imposed a $50 reimbursement limitation for nonemergent medical services provided by emergency department physicians, according to court documents filed Oct. 7.

Emergency Medical Care Facilities, a company that provides services in Tennessee emergency departments, said TennCare did not follow the correct procedure for making the $50 cap rule under the Uniform Administrative Procedures Act. The case required the appeals court to determine whether the rule falls under the UAPA.

The trial court had determined that the $50 cap rule is defined as a “rule” by the UAPA, is subject to the law’s requirements, and that TennCare did not comply with the law’s requirements for rule-making.

TennCare appealed the decision. The appeals court determined that the $50 cap rule is not subject to the UAPA because it falls under the internal management exception in the 2009 version of the law, reversing the trial court decision.